A patient with a history of laparoscopic Nissen fundoplication with mesh and other abdominal surgeries with a large recurrent paraesophageal hernia. Reoperation for PEH repair demonstrates a significant desmoplastic reaction to mesh that extends into the mediastinum. Dissection is tedious and it is difficult to delineate tissue planes. Careful and persistent dissection leads to eventual reduction of the herniated stomach the mediastinum and takedown of the prior fundoplication. Care is taken to identify fragmented mesh throughout the dissection and explant it as needed. The hiatal hernia is repaired and biologic mesh placed. A posterior fundoplication is created with gastropexy prior to closure.